Research article

Clinical research evidence of cupping therapy

in China: a systematic literature review

Huijuan Cao, Mei Han, Xun Li, Shangjuan Dong, Yongmei Shang, Qian Wang, Shu Xu

and Jianping Liu*

Corresponding author: Jianping Liu jianping_l@hotmail.com

Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, 100029,

China

BMC Complementary and Alternative Medicine 2010, 10:70 doi:10.1186/1472-6882-10-70 The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1472-6882/10/70 Received: 31 May 2010 Accepted: 16 November 2010 Published: 16 November 2010 © 2010 Cao et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Though cupping therapy has been used in China for thousands of years, there has been no

systematic summary of clinical research on it.

This review is to evaluate the therapeutic effect of cupping therapy using evidence-based

approach based on all available clinical studies.

Methods

We included all clinical studies on cupping therapy for all kinds of diseases. We searched six

electronic databases, all searches ended in December 2008. We extracted data on the type of

cupping and type of diseases treated.

Results

550 clinical studies were identified published between 1959 and 2008, including 73 randomized

controlled trials (RCTs), 22 clinical controlled trials, 373 case series, and 82 case reports.

Number of RCTs obviously increased during past decades, but the quality of the RCTs was

generally poor according to the risk of bias of the Cochrane standard for important outcome

within each trials. The diseases in which cupping was commonly employed included pain

conditions, herpes zoster, cough or asthma, etc. Wet cupping was used in majority studies,

followed by retained cupping, moving cupping, medicinal cupping, etc. 38 studies used

combination of two types of cupping therapies. No serious adverse effects were reported in the

studies.

Conclusions

According to the above results, quality and quantity of RCTs on cupping therapy appears to be

improved during the past 50 years in China, and majority of studies show potential benefit on

pain conditions, herpes zoster and other diseases. However, further rigorous designed trials in

relevant conditions are warranted to support their use in practice.

Background

Cupping therapy belongs to traditional Chinese medicine, the heritage from several thousand

years. It is used with one of several kinds of cups, such as bamboo cups, glasses or earthen cups,

placing them on the desired acupoints on patients' skin, to make the local place hyperemia or

haemostasis, which can obtain the purpose of curing the diseases [1]. The earliest records of

cupping is in Bo Shu (an ancient book written on silk), which was discovered in an ancient tomb

of the Han Dynasty in 1973[2]. Some therapeutic cupping methods and case records of treatment

were also described in early Chinese books. Zhao Xueming, a Chinese doctor practicing more

than 200 years ago, completed a book named "Ben Cao Gang Mu Shi Yi", in which he described

in detail the history and origin of different kinds of cupping and cup shapes, functions and

applications [3].

There are seven major types of cupping practice in China. Usually, cupping practitioners utilize

the flaming heating power to achieve suction (minus pressure) inside the cups to make them

apply on the desired part of the body. This basic suction method of cupping therapy is called

retained cupping, which is most commonly used in Chinese clinics as the first type of cupping.

Besides this kind of suction, different types of cupping composed with different methods. The

second type of cupping is bleeding cupping (or wet cupping), which contains two steps: before

the suction of the cups, practitioners should make some small incisions with a triangle-edged

needle or plum-blossom needle firmly tapping the acupoint for a short time to cause bleeding;

the third one is moving cupping, which practitioners should control the suction by gently moving

the cup toward one direction; then is empty cupping, which means the cups are removed after

suction without delay; or needle cupping, which should apply the acupuncture first, then apply

the cups over the needle. Cupping practitioners may also used other methods of suction, such as

medicinal (herbal) cupping, which used bamboo cups, usually put the cups and herbal into a deep

pan with water and boiled them together, after 30 minutes apply the cup suction on specific

points according to steam instead of fire; or water cupping which is a technique involves filling a

glass or bamboo cup one-third full with warm water and pursuing the cupping process in a rather

quick fashion. Each kind of cupping therapy may be used for different diseases or different

purposes of treatment.

Because cupping is widely used in Chinese folklore culture, the technique has been inherited by

the modern Chinese practitioners. In the 1950s the clinical efficacy of cupping was confirmed by

Co-Research of China and acupuncturists from the former Soviet Union, and was established as

an official therapeutic practice in hospitals all over China [4]. This issue substantially stimulated

the development of further cupping research.

In the context of evidence-based medicine (EBM), we need to evaluate therapeutic effect of

cupping therapy to inform the practice heritage from ancient time.

Methods

Inclusion Criteria

Any type of clinical studies including randomized controlled trials (RCTs), clinical controlled

trials (CCTs), case series (CSs), and case reports (CRs) indentifying the therapeutic effect of

cupping therapy, including one or more than two types of cupping methods, compared with no

treatment, placebo or conventional medication were included. Combined therapy with cupping

and other interventions compared with other interventions alone were also included. Cupping

therapy combined with other TCM therapies (including acupuncture) compared with non-TCM

therapies were excluded. There was no limitation on language and publication type. Multiple

publications reporting the same data of patients were excluded.

Identification and selection of studies

We searched China Network Knowledge Infrastructure (CNKI) (1911-1978, 1979-2008),

Chinese Scientific Journal Database VIP (1989-2008), Wan Fang Database (1985-2008),

Chinese Biomedicine (CBM) (1978-2008), PubMed (1966-2008) and the Cochrane Library

(Issue 4, 2008), all the searches ended at December 2008. The search terms included "cupping

therapy", "bleeding cupping", "wet cupping", "dry cupping", "flash cupping", "herbal cupping",

"moving cupping" or "retained cupping". Four authors (SJ Dong, YM Shang, Q Wang, and S

Xu) were involved in study identifying and each of them selected one fourth of the studies for

eligibility and checked against the inclusion criteria independently, they all cross checked the

results with other authors.

Data extraction and quality assessment

Four authors (SJ Dong, YM Shang, Q Wang, and S Xu) extracted the data from the included

trials independently, and each of them was in charge with one fourth of the included trials.

Another author (HJ Cao) checked the data and did the summary of their results. The extracted

data included authors and title of study, year of publication, study design (detail of

randomization if the study was RCT), type of disease, study size, age and sex of the participants,

type of cupping therapy, treatment process, detail of the control interventions, outcome (for

example, total effective rate), and adverse effect for each study. All data were extracted from the

published studies.

Evidence from RCT is considered as gold standard for therapeutic evaluation, we specifically

evaluate the methodological quality of RCT in this review. Two authors (HJ Cao and M Han)

evaluated the quality of included RCTs. Assessment of methodological quality of RCTs was

carried out using criteria from the Cochrane Reviewers' Handbook [5]. We assessed studies

according to the risk of bias for each important outcome within included trials, including

adequacy of generation of the allocation sequence, allocation concealment, blinding and outcome

reporting. The quality of all the included trials was categorized to low/unclear/high risk of bias.

Trials which met all criteria were categorized to low risk of bias, trials which met none of the

criteria were categorized to high risk of bias, and other trials were categorized to unclear risk of

bias if insufficient information acquired to make judgment.

Data analysis and statistical methods

Data were extracted using Microsoft Access, and all the information and data were transferred

into forms of Excel to be calculated for frequency. Data were summarized using risk ratio (RR)

with 95% confidence intervals (CI) for binary outcomes or mean difference (MD) with 95% CI

for continuous outcomes. Revman5.0.20 software was used for data analyses. Meta-analysis was

used if the trials had a good homogeneity on study design, participants, interventions, control,

and outcome measures. Publication bias was explored by funnel plot analysis.

Results

Basic information of studies

After primary searches from six databases, 4696 citations were identified, and the majority was

excluded due to obvious ineligibility from reading title/abstract, and full text papers of 550

studies were retrieved. At last, all of the 550 studies were included in this review, which included

525 studies published in Chinese, 1 study published in English, 20 unpublished conference

papers and 4 unpublished dissertation papers[7,15,30,39] (Figure 1).

The process of including and excluding studies

All the included studies which were published between 1959 and 2008, including 73 RCTs [6-78], 22

CCTs, 373 CSs, and 82 CRs. 214 studies (38.9%) were published between 1999 and 2008, and the

number of studies has increased over the course of five decades obviously (Figure 2). The first RCT

published in 1993 and over half of the involved RCTs were reported between 2006 and 2008.

Numbers of studies on cupping therapy by study type between 1958 and 2008

Description of interventions

Among all the included studies, 319 (58.0%) used bleeding cupping as the main intervention,

100 (18.2%) used retained cupping, 48 (8.7%) used moving cupping, 30 studies (5. 5%) used

medicinal cupping, 7 (1.3%) used flash cupping, 5 (0.9%) used water cupping, and 3 (0.6%) used

needle cupping, combined cupping which used at least two types of cupping methods was used

in 38 studies (6.9%) (Figure 3).

Constituent ratio of types of cupping therapy

Distribution of diseases/conditions

More than 50 kinds of diseases or symptoms were treated by cupping therapy according to

included studies. The top 20 diseases/conditions in which cupping is commonly employed were

pain (70 studies), herpes zoster (59 studies), cough or asthma (39 studies), acne (29 studies),

common cold (24 studies), urticaria (22 studies), lateral femoral cutaneous neuritis (21 studies),

cervical spondylosis (19 studies), lumbar sprain (19 studies), scapulohumeral periarthritis (17

studies), mastitis (14 studies), facial paralysis (13 studies), Bi syndrome (Wind, cold and

dampness invading the body, which is caused by changeable climate and alternate cold and heat,

or dwelling in damp places, or wading, or being caught in the rain, and linger in channels and

joints resulting in Bi syndrome as the result of stagnation of qi and blood, 13 studies), headache

(13 studies), soft tissue injury (10 studies), arthritis (10 studies), neurodermatitis (10 studies),

wound and sious (8 studies), sciatica (7 studies) and myofascitis (6 studies), 264 studies were

concerned on other diseases treated by cupping therapy (Figure 4).

Constituent ratio of the diseases which were reported in literatures that were treated by cupping therapy

Among the top 20 diseases in this review, 12 of them were pain related, including chronic

muscle pain (100 studies, such as low back pain, skelalgia, fibromyalgia, etc); generalized pain

(93 studies, such as lumbar sprain, etc); infection pain (59 studies, herpes zoster); and neuralgia

pain (20 studies, such as headache and sciatica). Relieving pain was the main purpose of treating

with cupping therapy of these studies. Retained cupping, moving cupping, or wet cupping

therapy was usually used in these studies.

Beside pain, respiratory disease, such as common cold and symptom of cough and asthma are

also treated by cupping therapy. Common cold is caused by wind and cold pathogen according to

TCM theory, moving cupping along Du meridian may regulate the qi, expelling wind and

clearing away cold. Dingchuan (EX-B1) is an acupoint belonging to Extra Meridian, which is

effective on relieving asthma and cough symptoms. Retained cupping or wet cupping therapy on

Dingchuan is usually used on cough and asthma.

Acne belongs to disorders of skin appendages, neurodermatitis and urticaria belong to disease of

skin and subcutaneous tissue. All these three diseases may be caused by over heat in blood

system according to TCM theory. Thereby, wet cupping therapy is popularly used for these

diseases.

Facial paralysis is a kind of nerve root and plexus disorders, which belongs to disease of the

nerve system. Flashing cupping and moving cupping are commonly used on this disease by

regulating the circulation of qi and blood, expelling wind and clearing away cold, and channel

meridians.

Mastitis is a kind of disease of the genitourinary system, is an inflammatory disorders of breast.

Wet cupping therapy is commonly used and acupoints belonged to liver meridian are always

chosen for the blood-letting before cups retained. Some of the studies also used retained cupping

therapy on nipple to utilize the negative pressure to cause milk ejection, which is applied to

patients with galactostasis. The same theory is used for patients with wound and sious that

retained cupping therapy may help discharge pus.

We also counted the number of studies of the top 20 diseases by study type between 1994 and

2008 (Figure 5).

Methodological quality of RCTs

According to our pre-defined methodological quality criteria, no trial could be evaluated as low

risk of bias, the majority of the 73 included trials were evaluated as high risk of bias (Table 1:

Reporting of five quality components in randomized clinical trials on cupping therapy). None of

the trials reported sample size calculation, 15 trials described randomization procedures (such as

random number table or computer generated random numbers), but none of them reported

allocation concealment. Three trials mentioned blinding, but only one trial reported that they

blinded outcome assessors, the other two trials did not report who were blinded. Two trials

reported the number of dropouts, but none of them used intention-to-treat analysis.

Reporting of five quality components in randomized clinical trials on cupping therapy

There were 48 (65.8%) trials reported the comparability of baseline data, 18 (24.7%) trials

specified the inclusion criteria, 17 (23.3%) trials specified the exclusion criteria and 48 (65.8%)

trials described the diagnostic criteria. 67 (91.8%) trials reported the efficacy standard, but 51

(69.9%) out of 73 trials used composite outcome measure which categorized the effect of the

treatment into four grades (cured, markedly effective, effective, ineffective) according to the

change of the symptoms, the remaining 16 trials (21.9%) used single outcome measure for

therapeutic effect. Symptoms were commonly used as outcome measurements, which were

applied in 34 (46.6%) trials.

Estimate effects of RCTs with cupping

Due to the insufficient RCTs and the variations in study quality, participants, intervention,

control and outcome measures of the included RCTs, the results of most of the studies could not

be synthesized by quantitative method. Though most of the studies showed that cupping therapy

was significant effective on certain diseases, the interpretation of the positive findings from the

individual studies need to be incorporated with the clinical characteristics of the included studies

and evidence strength. Therefore, the conclusion of the beneficial effect of cupping therapy

needs to be confirmed in large and rigorously designed RCTs.

We conducted a systematic review [80] (in press) of 8 RCTs to evaluate therapeutic effect of wet

cupping therapy for herpes zoster, the meta-analyses showed that wet cupping was superior to

medications for the number of cured patients (RR 2.49, 95%CI 1.91 to 3.24, p < 0.00001), the

number of patients with improved symptom (RR 1.15, 95%CI 1.05 to 1.26, p = 0.003), and the

incidence rate of post-herpetic neuralgia (RR 0.06, 95%CI 0.02 to 0.25, p = 0.0001).

Combination of wet cupping and medications was significantly better than medications alone on

number of cured patients (RR 1.93, 95%CI 1.23 to 3.04, p = 0.005), but no difference in

symptom improvement (RR 1.00, 95%CI 0.92 to 1.08, p = 0.98).

We also conducted a systematic review [81] of RCTs to evaluate the therapeutic effect of TCM

therapies for fibromyalgia, only 3 trials [82-84] on cupping therapy were included in the review

according to the inclusion criteria, and two of them could be conducted in meta-analysis

according to VAS (Visual Analogue Scale) and HAMD (Hamilton Depression Scale) scores after

treatment. These sub-analysis of 2 out of 25 trials showed that compared to medications alone,

cupping therapy combined with acupuncture plus medications was significantly better on pain

relieving (MD -1.66, 95%CI -2.14 to -1.19, p < 0.00001) and depression remission (MD -4.92,

95%CI -6.49 to -3.34, p < 0.00001).

Serious adverse effects were not reported in any of the trial publications.

Discussion

According to our findings, clinical studies on cupping therapy were obviously improved either

on number or quality during the last 50 years. Though the methodological quality of the included

RCTs were generally poor, some quality items showed that it was improved during the last 10

years, such as the number of the RCTs which reported the sequence generation of randomization

(Table 1: Reporting of five quality components in randomized clinical trials on cupping therapy).

But we should wake up to that these studies leave much scope for well designed, conducted and

reported trials. We included 550 clinical studies in this review, only 73 RCTs were published in

the last two decades, 78.1% of these RCTs were with high risk of bias. According to the

Consolidated Standards of Reporting Trials (CONSORT) [85], randomization methods need to

be clearly described and fully reported. Although blinding of the cupping therapy might be very

difficult, blinding of outcome assessors and statistics should be attempted as much as possible to

minimize performance and assessment biases. Sample size calculation and analysis of outcomes

based on intention-to-treat principle are important. Similar to acupuncture, cupping therapy is a

kind of treatment which relevant to meridian and acupoints, so researchers may consult to the

standard of STRICTA [86] on trial report, which means details of cupping treatment should be

reported, such as type of cups, experience of the practitioners, period and frequency of the

treatment.

About one third of the included RCTs did not report the diagnostic criteria, 63.0% of the RCTs

did not report the criteria of inclusion and exclusion, and the use of composite outcome measures

in 51 (69.9%) trials to evaluate overall improvement of symptoms, all the issues limit the

generalization of the findings. The classification of "cure", "markedly effective", "effective" or

"ineffective" is not internationally recognized, and it is hard to interpret the effect. All of the

above uncertain items may increase the clinical heterogeneity. We suggest future trials

completely report all the criteria they chose and comply with international standards in the

evaluation of treatment effect.

We searched PubMed database using the above searching strategy, only 2 RCTs were published

by international researchers outside of China until 2008. One tested wet cupping therapy on

serum lipid concentrations [87], which concluded that wet cupping may be an effective method

of reducing LDL cholesterol in men and consequently may have a preventive effect against

atherosclerosis. Another study tested wet cupping therapy for nocturnal brachialgia paraesthetica

[88], which suggested short-term effects of a single wet cupping therapy. Meanwhile, two further

RCTs with cupping originating outside China have been published after 2008, demonstrating

increasing interest in this field. One trial [89] found that traditional wet-cupping care was

significantly more effective in reducing bodily pain than usual care at 3-month follow-up with

satisfactory safety and acceptance to patients with nonspecific low back pain. Another trial [90]

investigated the effectiveness of cupping therapy with the conclusion that cupping therapy may

be effective in relieving pain and other symptoms related to carpal tunnel syndrome (CTS),

however, the efficacy of cupping in the long-term management of CTS and related mechanisms

remains to be clarified. We are glad to see that these trials are apparently with good

methodological quality, however, though most of the clinical trials showed positive results on

therapeutic effect of cupping therapy, the appropriate duration of the cupping therapy, the

syndrome differentiation for acupoints selection, and the frequency of the cupping therapy were

unclear according to current evidence. Future studies should address these issues.

This review suggests that there is insufficient high-quality evidence to support the use of cupping

therapy on relevant diseases. Although quite a number of clinical studies reported that cupping

therapy may have effect on pain conditions, herpes zoster, symptoms of cough and asthma, acne,

common cold, or other common diseases. The current evidence is not sufficient to allow

recommendation for clinical use of cupping therapy for the treatment of above diseases of any

etiology in people of any age group. The long-term effect of cupping therapy is not known, but

use of cupping is generally safe based on long term clinical use and reports from the reviewed

clinical studies.

The number of RCTs on treatment using cupping therapy is scarce in terms of a specific disease.

Existing trials are of small size and low methodological quality. Further high quality studies of

larger sample size are needed to assess the effectiveness of cupping therapy. It might be

worthwhile to examine the effectiveness of cupping therapy or combination of cupping therapy

with other non-pharmacological or pharmacological treatments for pain conditions, herpes

zoster, symptoms of cough and asthma, acne, common cold, or other common diseases which

were most treated by cupping therapy according to this review. In addition, the methodological

quality should be improved, and the study design and report should also be standardized. The

protocol of the study should be registered in authoritative organizations [91], such as WHO

International Clinical Trial Registration Platform (WHO ICTRP).

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

HC participated in the design of the study, searched studies, participated in extracted data,

assessed study quality, analyzed data, performed the statistical analysis and drafted the

manuscript. MH participated in extracted data, assessed study quality. XL co-developed the full

text of the review. SD, YS, QW, SX participated in searched literature, identified clinical studies

for inclusion and extracted data. JL conceived of the study, and participated in its design and

coordination, co-developed the full text of the review and is the corresponding author.

Acknowledgements

Huijuan Cao and Jianping Liu were supported by a grant from the National Basic Research

Program of China ('973' Program, No. 2006CB504602), the grant of international cooperation

project (No. 2009DFA31460) and the 111 Project (B08006) from China. Jianping Liu was in part

supported by the Grant Number R24 AT001293 from the National Center for Complementary

and Alternative Medicine (NCCAM) of the US National Institutes of Health.

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Pre-publication history

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